Clinical Anatomy of the Spine, Spinal

Cord, and ANS 3rd Edition

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 THIRD EDITION

Clinical Anatomy of the

SPINE,
SPINAL CORD,
and ANS
GREGORY D. CRAMER, DC, PhD
Professor of Anatomy
Professor and Dean
Department of Research
National University of Health Sciences
Lombard, Illinois

SUSAN A. DARBY, PhD

Professor of Anatomy
Department of Basic Sciences
National University of Health Sciences
Lombard, Illinois

Illustrators
Theodore G. Huff, BA, MFA (second and third editions)
Sally A. Cummings, MA, MS (first edition)

Photographers
Ron Mensching, BS (first and second editions)
Kadi Sistak (third edition)

With 559 illustrations

Introduction
This book has been organized with two groups of read-
ers in mind: those studying the spine for the first time and
those clinicians and researchers who have previously studied
the spine in detail. Therefore we have accepted the daunt-
ing task of designing a book to act as a source of reference
and as a book that is “readable.” To this end an outline has
been included at the beginning of each chapter. This format
should help the reader organize his or her thoughts before
beginning the chapter and also provide a quick reference
to the material of interest. A complete subject index is also
included at the end of the text for rapid referencing. In addi-
tion, items of particular clinical relevance and the results of
clinically relevant research appear with a red bracket beside
the material throughout the book. This highlighting proce-
dure is meant to aid students and clinicians alike focus on
areas that are thought to be of particular current importance
in the detection of pathologic conditions or in the treatment
of disorders of the spine, spinal cord, and autonomic ner-
vous system. Discussions of the clinical relevance of ana-
tomic structures are included to relate anatomy to clinical
practice as efficiently as possible.
Chapter 1 discusses surface anatomy. It contains infor-
mation useful not only to the student who has yet to palpate
his or her first patient, but also to the clinician who examines
patients on a daily basis. Chapters 2 and 3 relate the gen-
eral characteristics of the spine and spinal cord, using a basic
approach. These chapters are directed primarily to the nov-
ice student. A quick review of these chapters, with attention
focused on the sections highlighted by red brackets, should
also be of benefit to the more advanced student. Chapter 2
includes a section on advanced diagnostic imaging. This sec-
tion is provided for the individual who does not routinely
view advanced imaging. A brief description of the strengths
and weaknesses of computed tomography and magnetic
resonance imaging and a concise overview of other less fre-
quently used advanced imaging procedures are included.
Chapters 3 and 4 relate soft tissues to the “bones” by describ-
ing the spinal cord and its meningeal coverings, and the
muscles that surround and influence the spine. This material
is followed by a detailed study of the regional anatomy of the
spine in Chapters 5 through 8. These chapters also include
information concerning the ligamentous tissues of the spine.
A more thorough presentation of the anatomy of the spinal
cord and autonomic nervous system is found in Chapters 9
and 10, and the development (from inception to adulthood)
and histologic composition of the spine and spinal cord are
found in Chapters 12 through 14.
It should be noted that the first four chapters provide
the groundwork for later chapters that are more detailed
and contain additional information with specific clini-
cal relevance. Therefore certain material is occasionally
discussed more than once. For example, Chapters 2 and
3 are concerned with general characteristics of the spine
and spinal cord, with a discussion of the various compo-
nents of a typical vertebra, the vertebral canal, and the spi-
nal cord within the canal. These structures are discussed
again regionally (Chapters 5 through 8) to a much greater
depth to explore their relative importance and clinical
significance in each region of the spine and to appreci-
ate the neuroanatomic connections within the spinal cord
­(Chapter 9).
Chapter 11 is devoted to pain producers (those structures
that receive nociceptive innervation), the mechanisms and
neuroanatomic pathways of nociception from spinal struc-
tures, and the peripheral, spinal, and supraspinal modula-
tion of these impulses. This chapter is designed for readers
who have already completed study in spinal anatomy and
neuroanatomy. Chapter 12 discusses the development of
the spine and is designed for use by students studying spinal
anatomy and for clinicians who wish to refresh their knowl-
edge of the development of the spine and spinal cord. Chap-
ter 13 covers the pediatric spine and should be useful to all
readers. Chapter 14 describes the microscopic anatomy of
the zygapophysial joints, intervertebral discs, and all other
spine-related tissues. Because much of the current research
on the spine is focused at the tissue, cellular, and subcellular
levels, both students and clinicians should find this chapter
useful at some point in their careers. Because of the rather
specialized nature of the last four topics, they have been
positioned at the end of the book.
xi
Introduction
Clarification of Abbreviations and Terms
Vertebral levels are frequently abbreviated throughout this
text. The initials C, T, and L are used to abbreviate cervical,
thoracic, and lumbar, respectively. Vertebral levels can then
be easily identified by placing the appropriate number after
the abbreviated region. For example, “T7” is frequently used
rather than “the seventh thoracic vertebra.”
In addition, some potentially confusing terminology
should be clarified. Throughout this text the term kypho-
sis is used when referring to a spinal curve that is concave
anteriorly, and the term lordosis is used for a curve that is
concave posteriorly. The term hyperlordosis refers to an
accentuation of a lordosis beyond what is usually accepted
as normal, and the term hyperkyphosis is used for an accen-
tuation of a kyphosis beyond the range of normal. This is in
contrast to the terminology of some texts that refer to nor-
mal spinal curves as being “concave anteriorly” or “concave
posteriorly” and reserve the terms “kyphosis” and “lordo-
sis” for curves that are deeper than normal. Although both
sets of terminology are correct, the prior one was chosen for
this text because we felt that this terminology would lend the
most clarity to subsequent discussions.
xii
The spellings “zygapophyseal” and “zygapophysial” are
both considered correct. The terms are most often used
when referring to the most appropriate name of the spinal
“facet joints,” that is, the “zygapophysial joints.” We have
chosen “zygapophysial” because most researchers in the field
use this spelling.
Finally, we hope that you, the reader, believe as we do
that the long-standing interest of clinicians in the anatomic
sciences is not an accident. Greater awareness of structure
leads to a keener perception of function, and an increased
understanding of pathologic conditions is the natural con-
sequence. This results in a better comprehension of cur-
rent therapeutic approaches and the development of new
treatment procedures based upon a scientific foundation.
Therefore astute clinicians are vigilant for developments in
the structural sciences, being aware that their concepts of
human mechanisms may be influenced by new discoveries
in these disciplines. Whenever new information about the
causes underlying dysfunction is available, new therapeutic
approaches are sure to follow, and clinicians who have kept
abreast of these recent discoveries will find themselves lead-
ers in their field.
Acknowledgments
This project would not have been possible without the sup-
port of the members of the administration, faculty, students,
and staff of the National University of Health Sciences, who
allowed us the time and facilities necessary to review the lit-
erature, write several drafts of text, and work on the devel-
opment of supporting figures. We greatly appreciate their
support of, and in some instances commitment to, this work.
In addition, many people have helped with the produc-
tion of this book. We would like to take this opportunity to
thank those who helped with proofreading portions of vari-
ous drafts of the first through third editions of this work and
whose suggestions were extremely helpful in the develop-
ment of the final manuscripts. These people include Robert
Appleyard, PhD; Joe Cantu, DC; Jim Christiansen, PhD; John
DeMatte, DC; Richard Dorsett, DC; Rebecca Furlano, DC;
Kris Gongaware, DC; Michael Kiely, PhD; Joshua K. Mack;
Allan Mathieu, DC; James McKay, DC; Nathan Miller, DC;
Carol Muehleman, PhD; Ken Nolson, DC; Joseph Papuga,
DC; Nyarai S. Paweni; and Nancy Steinke, MS. A special
thanks to Lynn Zoufal, MBA, who spent countless hours key-
ing in editorial changes to the second edition manuscripts.
We would also like to thank Patrick W. Frank, DC, for his
beautiful dissections of the muscles of the back, which appear
in Chapter 4. The work of Victoria Hyzny, DC, and Terese
Black, DC, ND, in the dissections that appear in Chapters
3, 5, 9, and 10 is greatly appreciated. The inexhaustible sup-
port of Joshua W. Little, DC, PhD, who performed countless
literature searches and monitored the files for the literature
for the second edition, was extremely valuable. Rebecca Fur-
lano, DC, and Jennifer Dexheimer, BS, MT, assumed these
important roles for the third edition. Christopher Allin, DC;
Kim Anderson, DC; Terese Black, DC, ND; Jordan Bray;
Matt Imber, DC; Anna M. Rodecki, DC; Gina Sirchio, DC;
Michelle Steinys, DC; and Matt White, DC, also assisted
with searching the literature and compiling the reference
lists, and we thank them. We thank Judy Pocius, MS; Sheila
Meadows, DC; and Terese Black, DC, ND, for organizational
help with photographs and illustrations for the first and sec-
ond editions. We are also grateful for the graphic support
of Robert Hansen, BFA, and the computer graphics added
by Dino Juarez, MA, to several of the magnetic resonance
imaging scans found in Chapters 11 and 13. We are also
grateful for the continuous support (from the first edition
to the present) of the faculty and staff of the NUHS Learning
Resource Center, especially Peggy Carey, BS, LTA, and Russ
Iwami, MALS, for filling countless requests for difficult to
find papers, many interlibrary loan requests, and innumer-
able additional requests for help.
The magnetic resonance imaging scans, computed tomo-
grams, and x-ray films were graciously provided and labeled
by William Bogar, DC, DACBR, of the National University
of Health Sciences and Dennis Skogsbergh, DC, DABCO,
DACBR. Many of the x-rays of spinal pathology and con-
genital anomalies were provided by Jeffery A. Rich, DC,
DACBR. We would like to thank them for their contribu-
tions to this text. Where possible, diagnostic images are pre-
sented in a larger format than in the first edition (thank you
for the suggestion, Dr. Barber).
We thank Michael L. Kiely, PhD, for his review of the
entire manuscript for the first edition. We also appreciate
the work and patience of the publishing staff at Elsevier Inc.,
particularly that of the executive editors: James Shanahan
and Martha Sasser for the first edition; Christie Hart and
Kellie White for the second edition; and Kellie White and
Joe Gramlich for the third edition, and our project manager,
Jeanne Genz. And, thanks to Thomas Grieve, DC, MPH for
his help in proofreading the pages.
We would also like to gratefully acknowledge our parents,
Dr. and Mrs. David Cramer (David deceased, March 2012,
and Louise deceased, August 2012) and Mr. and Mrs. George
Anderson (George deceased, May 2006, and Helen deceased,
April 2011), whose encouragement and early instruction
gave us a strong desire to learn more and to help others.
The outstanding teaching and mentoring of Mr. Curtis Dee
Cooley and Drs. Joseph Janse, Delmas Allen, Liberato DiDio,
William Potvin, Frank Saul, Dennis Morse, Richard Yeasting,
Richard Lane, and Robert Crissman will never be forgotten.
Their example provided much of the motivation for begin-
ning, and completing, this endeavor. Thank you all very much.
Gregory D. Cramer
Susan A. Darby
xiii
Chapter 1
Surface Anatomy of the Back
and Vertebral Levels of Clinically
Important Structures
Barclay W. Bakkum
The Back, 1
Visual Landmarks of the Back, 2
Palpatory Landmarks of the Back, 3
Spinal Cord Levels versus Vertebral Levels, 6
Vertebral Levels of Structures in the Anterior Neck
and Trunk, 9
Visual Landmarks, 9
Deeper Structures, 10
Surface anatomy is defined as the configuration of the sur-
face of the body, especially in relation to deeper parts. A
thorough knowledge of surface anatomy is necessary for the
proper performance of a physical examination. Information
gathered by the eyes (inspection) and fingers (palpation) is
often critical in the assessment of a patient. An understand-
ing of the topography of the human body also allows the
health care provider to locate the position of deep structures
that may need further evaluation.
The locations of structures in reference to the surface of the
body are always approximations, although it has been shown
that reliability of locating spinal structures by palpation can
be enhanced by training and experience (Byfield et al., 1992;
Downey et al., 1999; Phillips et al., 2009). Individual varia-
tions are common and are influenced by such factors as age,
sex, posture, weight, and body type. Respiratory movements
also can have marked effects on the locations of structures,
especially those of the thorax. Determining the position of
the contents of the abdomen can be particularly challenging,
and the precise location of abdominal viscera can be estab-
lished only by verification with appropriate diagnostic imag-
ing procedures.
In keeping with the scope of this text, the surface anatomy
included in this chapter is limited to the back. Spinous pro-
cesses and posterior bony landmarks are used as points of ref-
erence in the first part of the chapter. One reason for the use
of these as landmarks is to help clinicians with examination
and treatment of the back and spine when the patient is in the
prone position. In addition, the vertebral levels of structures
of the anterior neck and trunk, which are either visible by
means of advanced imaging procedures (magnetic resonance
PART ONE
imaging [MRI] or computed tomography [CT]) or palpable
during physical examination, are included. Knowledge of
the normal relationships between the viscera and the spine is
becoming increasingly important in clinical practice, since cli-
nicians are asked with greater frequency to interpret or review
studies employing these advanced imaging procedures. On a
more practical level, knowledge of these relationships helps
the clinician quickly become oriented with the vertebral level
of diagnostic images taken in the horizontal plane.
Because other texts discuss the location of organs with
regard to abdominal regions or quadrants, that method of
locating organs is not covered here.
The Back
The back, or dorsum, is the posterior part of the trunk and
includes skin, muscles, the vertebral column, spinal cord,
and various nerves and blood vessels (Gardner, Gray, &
O’Rahilly, 1975). The 24 movable vertebrae consist of, from
superior to inferior, 7 cervical (C), 12 thoracic (or dorsal)
(T), and 5 lumbar (L). Inferior to the lumbar vertebrae, five
sacral vertebrae (S) fuse in the adult to form the sacrum. The
lowermost three to five vertebrae fuse late in adult life to
form the coccyx (Co).
Intervertebral discs are located between the anterior
portions of the movable vertebrae and between L5 and the
sacrum. There is no disc located between the occiput and C1
(atlas), or between C1 and C2 (axis). The discs are named for
the vertebra found immediately above the disc; that is, the
T6 disc is located between the T6 and T7 vertebrae.
Seven processes arise from the posterior portion of the
typical vertebra. Several atypical vertebrae have variations
in their anatomy and are discussed in Chapters 5, 6, and 7.
The spinous process is a midline structure that is directed
posteriorly and to a variable degree inferiorly. The transverse
processes are a pair of lateral projections. The other four
processes are articular, and each vertebra has a superior pair
and an inferior pair. These processes are discussed in greater
detail in Chapter 2.
The remainder of this chapter discusses visual landmarks
of the back, palpatory landmarks of the back, spinal cord lev-
els versus vertebral levels, and vertebral levels of structures
1
PART ONE
Characteristics of the Spine and Spinal Cord

External occipital protuberance

C7 spinous process

T1 spinous process

Trapezius m.

Median furrow

Latissimus dorsi m.

Erector spinae m.

Posterior superior iliac spine

Gluteal cleft

Gluteal fold

FIG. 1-1 Landmarks of the back.

in the anterior neck and trunk. This information enables the
clinician to gain a thorough understanding of surface anat-
omy and serves as a reference for future patient assessment,
both in the physical examination and through diagnostic
imaging procedures, including plain film x-ray examination,
CT, and MRI.
Visual Landmarks of the Back
In the midline of the back is a longitudinal groove known
as the median furrow (or sulcus) (Fig. 1-1). Superiorly it
begins at the external occipital protuberance (EOP) (see the
following discussion) and continues inferiorly as the gluteal
(anal, natal, or cluneal) cleft (or crena ani) to the level of the
S3 spinous tubercle, the remnants of the spinous process of
S3. It is shallow in the lower cervical region and deepest in
the lumbar region. The median furrow widens inferiorly to
form an isosceles triangle with a line connecting the poste-
rior superior iliac spines (PSISs) forming the base above, and
the gluteal cleft forming the apex of the triangle below. The
PSISs are often visible as a pair of dimples located 3 to 4 cm
lateral to the midline at the level of the S2 spinous tubercle.
These indentations are known as the lateral lumbar fossae or
dimples of Venus. The gluteal fold (or sulcus) is a horizontal
skin fold extending laterally from the midline and roughly
corresponds with the inferior border of the gluteus maximus
muscle. This fold marks the lower extent of the buttocks.

2
 Chapter 1 – Surface Anatomy of the Back and Vertebral Levels of Clinically Important Structures
Several muscles are commonly visible in the back region.
The trapezius is a large, flat, triangular muscle that originates
in the midline from the EOP to the spinous process of T12
and inserts laterally onto the spine of the scapula. Its upper
fibers form the “top of the shoulder,” where the neck later-
ally blends into the thorax. The latissimus dorsi, extending
from the region of the iliac crest to the posterior border of
the axilla, forms the lateral border of the lower thoracic por-
tion of the back. This muscle is especially noticeable when
the upper extremity is adducted against resistance. Between
the trapezius medially and the latissimus dorsi laterally, the
inferior angle of the scapula may be seen at approximately
the level of the T8 spinous process. The erector spinae mus-
cles form two large longitudinal masses in the lumbar region
that extend approximately a hand breadth (10 cm) laterally
from the midline. These muscle masses are responsible for
the deepening of the median furrow in this region.
Besides these muscles, several bony landmarks usually are
visible in the region of the back. The spinous process of C7
(the vertebra prominens) usually is visible in the lower cer-
vical region. Often, the spinous processes of C6 and/or T1
also are visible, especially when the patient’s head is flexed.
Approximately 75% of the time, the C7 spinous process is
the most prominent of these structures (Stonelake, Burwell,
& Webb, 1988). In about 10% and 15% of the population,
the C6 and T1 spinous processes, respectively, are actually
the most prominent spinous processes in the region.
In the adult the vertebral column has several visible nor-
mal curves. In the cervical and lumbar regions the spine is
anteriorly convex (lordotic), and in the thoracic and sacral
areas it is posteriorly convex (kyphotic). Normally there is
no lateral deviation of the spinal column, but such curvature
is known as scoliosis when present. These curves are covered
in more detail in Chapter 2.
Palpatory Landmarks of the Back
The following structures usually are not visible but can be
located on palpation. Some of the structures in this discus-
sion of palpable landmarks cannot normally be felt, but their
relation to landmarks that can be localized is given.
Cervical Region. The EOP (inion) is in the center of the
occipital squama (Fig. 1-2). The superior nuchal line extends
laterally from the EOP. The transverse process of the atlas
may be found directly below and slightly anterior to the mas-
toid process of the temporal bone. Care must be taken when
palpating this structure because of the relatively fragile sty-
loid process of the temporal bone that lies a few millimeters
anterior to the C1 transverse process and the great auricular
nerve that ascends in the fascia superficial to the C1 trans-
verse process.
The spinous process of the axis is the first readily palpable
bony structure in the posterior midline below the EOP (see
Fig. 1-2), although according to Oliver and Middleditch
(1991) the posterior tubercle of C1 may be palpable in some
people between the EOP and the spinous process of C2. In
Clinical Anatomy of the Spine, Spinal Cord, and ANS
the midline below the spinous process of the axis, the second
prominent palpable structure is usually the spinous pro-
cess of C7 or the vertebra prominens. In about 75% of the
population the vertebra prominens is the most prominent
spinous process, whereas the spinous process of C6 or T1 is
more evident in the other 10% and 15% of the population,
respectively (Stonelake, Burwell, & Webb, 1988). The other
cervical spinous processes are variably more difficult to pal-
pate. The spinous process of C3 is the smallest and can be
found at the same horizontal plane as the greater cornua of
the hyoid bone. The spinous process of C6 is the last freely
movable spinous process with flexion and extension of the
neck.
The zygapophysial joints between the articular processes
of the cervical vertebrae (collectively known as the left and
right articular pillars) can be found 1.5 cm lateral of the mid-
line in the posterior neck. With the exception of C1, the tips
of the transverse processes of the cervical vertebrae are not
individually palpable, but the posterior tubercles of these
processes form a bony resistance that may be palpated along
a line from the tip of the mastoid process to the root of the
neck, approximately a thumb breadth (2.5 cm) lateral of the
midline. The anterior aspects of the transverse processes of
the cervical vertebrae may be found in the groove between
the larynx and sternocleidomastoid muscle (SCM). It may
be necessary to slightly retract the SCM laterally to palpate
these structures. The anterior tubercles of the transverse
processes of C6 are especially large and are known as the
carotid tubercles (see Fig. 1-2). These may be palpated at the
level of the cricoid cartilage. Care must be taken when locat-
ing the carotid tubercles (and the other cervical transverse
processes), because they are in the proximity of the com-
mon carotid arteries, and they always should be palpated
unilaterally.
Anteriorly, the superior border of the thyroid cartilage,
forming the laryngeal prominence (Adam’s apple) in the
midline, may be used to find the horizontal plane of the C4
disc. The body of C6 is located at the same horizontal level as
the cricoid cartilage and the first tracheal ring.
Thoracic Region. The spinous process of T1 is usually the
third prominent bony structure in the midline below the
EOP; the spinous processes of C2 and C7 are the first and
second, respectively (Fig. 1-3). Note that in about 10% of the
population, the C6 spinous process is also very prominent.
The spinous process of T3 is located at the same horizontal
plane as the root of the spine of the scapula. The spinous
process of T4 is located at the extreme of the convexity of the
thoracic kyphosis; therefore it is usually the most prominent
spinous process below the root of the neck.
When patients are standing or sitting with their upper
extremities resting along the sides of their trunk, the inferior
scapular angle usually is at the horizontal level of the spi-
nous process of T8 (Cooperstein & Haneline, 2007; Haneline
et al., 2008). This changes when the patient is lying prone
with his or her upper extremities resting toward the floor in
3
PART ONE
Characteristics of the Spine and Spinal Cord
External
occipital
protuberance
C2
Vertebra
prominens
(C7)
FIG. 1-2 Palpable landmarks of the lateral neck.
a flexed position (the most common posture of the patient
when this region of the back is palpated). In this position the
scapulae are rotated so that the T9 spinous process is more
commonly found at the level of the inferior scapular angle
(Cooperstein et al., 2009).
The spinous processes of T9 and T10 often are palpably
closer together than other thoracic spinous processes, but
this is not a consistent finding. Located approximately half-
way between the level of the inferior angle of the scapula and
the superior margin of the iliac crests is the spinous process
of T12.
Because the spinous processes of the thoracic vertebrae
project in an inferior direction to different degrees, the
remainder of the vertebrae are located variably superior to
the tip of the spinous process of the same vertebral segment
4
Styloid
process of
temporal
bone
Greater
cornu of
hyoid bone
Laryngeal
prominence
Cricoid
cartilage
Carotid
tubercle
(Keogh & Ebbs, 1984). The tips of the transverse processes
of T1-4 and T10-12 are located one spinous interspace supe-
rior to the tip of the spinous process of the same segment.
The tips of the transverse processes of T5-9 are located two
spinous interspaces superior to the tips of their respective
spinous processes because these spinous processes project
inferiorly to a greater degree. For example, the tips of the
transverse processes of T3 are located in the same horizon-
tal plane as the inferior tip of the spinous process of T2,
whereas the tips of the transverse processes of T8 are at the
same horizontal plane as the inferior tip of the spinous pro-
cess of T6. The transverse processes of the thoracic vertebrae
progressively shorten from superior to inferior, so that the
tips of the transverse processes of T1 are located 3 cm lateral
to the midline, although those of T12 are 2 cm. Sometimes
 Chapter 1 – Surface Anatomy of the Back and Vertebral Levels of Clinically Important Structures
External
occipital
protuberance
Iliac crest
S2 spinous
tubercle
A
FIG. 1-3 A, Palpable landmarks of the back from a posterior view.
the transverse processes of T12 are small and not readily pal-
pable. The angles of the ribs may be palpated 4 cm lateral to
the midline at the horizontal levels of their respective trans-
verse processes.
Lumbosacral Region. The posterior aspects of the spinous
processes of the lumbar vertebrae differ from those of the
thoracic vertebrae in that they present more of a flat sur-
face. The spinous processes of L4 and L5 are shorter than the
other lumbar spinous processes and are difficult to palpate,
especially the L5 spinous process. The spinous process of L4
is the most inferior spinous process that has palpable move-
ment with flexion and extension of the trunk. In the past
the L4 spinous process was considered to be in a horizontal
plane with the superior margin of the iliac crests (the supra-
cristal plane), although in approximately 20% of the popu-
lation the tops of the iliac crests were thought to be aligned
Clinical Anatomy of the Spine, Spinal Cord, and ANS
C2
C7
T1
T7
Inferior angle
of the scapula
T12
L4
Posterior superior
iliac spine
Coccyx
Continued
with the spinous process of L5 (Oliver & Middleditch, 1991).
However, more recent evidence, using ultrasound to local-
ize intervertebral levels, shows the supracristal plane to be
at the level of L3-4 in nearly 75% of normal volunteers. In
the remainder of the healthy population, this plane is fairly
evenly found at either L2-3 or L4-5 (Pysyk et al., 2010).
The tips of the transverse processes of the lumbar verte-
brae are located approximately 5 cm lateral to the midline
and usually are not palpable. The mamillary processes are
small tubercles on the posterosuperior aspect of the superior
articular processes of the lumbar vertebrae. They are located
approximately a finger breadth (2 cm) lateral to the midline
at the level of the spinous process of the vertebra above and
are not readily palpable.
The second spinous tubercle, the remnants of the spinous
process of S2, is located at the extreme of the convexity of the
sacral kyphosis and is the most prominent spinous tubercle
5
PART ONE
Characteristics of the Spine and Spinal Cord
C7
T4
T7
L2
L4
B
FIG. 1-3, cont’d B, Anatomic relationships from a lateral view.
on the sacrum. It is also on the same horizontal plane as the
posterior superior iliac spines, which are readily palpable
3 to 4 cm lateral to the midline. The third spinous tubercle is
located at the upper end of the gluteal cleft. The lowest pal-
pable depression in the midline of the posterior aspect of the
sacrum is the sacral hiatus. There are four pairs of posterior
sacral foramina located 2.5 cm lateral to the midline and 2.5
cm apart, but usually these are not palpable. The tip of the
coccyx is the last palpable bony structure of the spine and
can be found in the gluteal cleft approximately 1 cm poste-
rior to the anus.
Spinal Cord Levels versus Vertebral Levels
The spinal cord is the extension of the central nervous system
outside the cranium (Fig. 1-4). It is encased by the vertebral
column and begins, on a gross anatomic level, at the foramen
magnum, located halfway between the inion and the spinous
process of C2. In the third fetal month the spinal cord, which
6
Lung apex T1
base T11
Aortic arch T4
Heart base T6
apex T10
Superior extent of
right hemidiaphragm T8
Right colic (hepatic)
flexure L2
Duodenal-jejunal junction L2
Aorta divides into
common iliac arteries L4
is developing from the neural tube, extends the entire length
of the embryo, and the spinal nerves exit the intervertebral
foramina (IVFs) at their level of origin (Sadler, 2010). How-
ever, with increasing development the vertebral column and
the dura mater lengthen more rapidly than does the neu-
ral tube, and the terminal end of the spinal cord gradually
assumes a relatively higher level. At the time of birth the tip
of the spinal cord, or conus medullaris, lies at the level of the
L3 vertebral body. In the adult the conus medullaris usually
is found at the L1-2 level (L1 body, 26%; L1 disc, 36%; L2
body, 20%), but may be found as high as the T12 disc (12%)
or as low as the L2 disc (6%) (Fitzgerald, 1985). Chapters 3
and 13 and Table 3-1 provide further details on the inferior
extent of the conus medullaris.
As a result of this unequal growth, the portion of the
spinal cord from which the respective pairs of spinal nerve
roots begin, known as the spinal cord level, is more supe-
rior than the level of the IVF from which the correspond-
ing spinal nerve exits. Therefore the spinal nerve roots run
 Chapter 1 – Surface Anatomy of the Back and Vertebral Levels of Clinically Important Structures
Conus medullaris
FIG. 1-4 Relationship between vertebral levels and spinal cord levels.
obliquely inferior inside the vertebral (spinal) canal from
their spinal cord level to their corresponding IVF. This
obliquity is not equal throughout the length of the vertebral
column. At the most superior levels of the vertebral column
the spinal nerve roots are nearly horizontal, and at more
inferior levels they are progressively more oblique. In the
lumbosacral region of the vertebral canal, the spinal nerve
roots are nearly vertical and form a bundle known as the
cauda equina.
A convenient method of locating various structures of the
neck and trunk is to relate them to the vertebra, or portion of
a vertebra, that lies at the same horizontal level as that struc-
ture. This plane is known as the vertebral level of a struc-
ture. Unless otherwise noted, the vertebral body serves as the
source of reference for the vertebral level. Table 1-1 lists the
vertebral levels of many of the clinically important visceral
structures in the anterior neck and trunk. When locating
structures within the vertebral canal, spinal cord levels must
Clinical Anatomy of the Spine, Spinal Cord, and ANS
C1
C7
T12
L5
be distinguished from vertebral levels. The cervical spinal
cord levels lie at even intervals between the foramen mag-
num and the spinous process of C6 (Keogh & Ebbs, 1984).
The upper six thoracic spinal cord levels are between the spi-
nous processes of C6 and T4, and the lower six thoracic spi-
nal cord levels are between the spinous processes of T4 and
T9. The lumbar, sacral, and coccygeal spinal cord levels are
located between the spinous processes of T10 and L1, where
the spinal cord ends as the conus medullaris.
The diameter of the spinal cord increases in two regions.
These spinal cord enlargements are formed by the increased
numbers of nerve cells necessary to innervate the limbs. The
cervical enlargement includes the C4-T1 spinal cord levels
and is at the level of the vertebral bodies of C4-7, or the spi-
nous processes of C3-6 (Keogh & Ebbs, 1984). The lumbar
enlargement is composed of the L2-S3 spinal cord levels and
is found at the level of the T10-L1 vertebral bodies or the
spinous processes of T9-12.
7
PART ONE
Characteristics of the Spine and Spinal Cord
Table 1-1 Vertebral Levels of Clinically Important Structures
Vertebral Level Structure Vertebral Level Structure
C1 Transition of medulla oblongata into spinal Inferior border of pectoralis major muscle
cord Inferomedial angles of posterior aspects of lungs
Hard palate Superior extent of left hemidiaphragm
Anterior portion of soft palate Superior pole of spleen
C2 Inferior border of free edge of soft palate Left extent of inferior border of liver
Nasopharynx and oropharynx join T10 Apex of heart
C2 disc Superior cervical ganglion Anteroinferior ends of oblique fissures of lungs
Esophageal hiatus (diaphragm)
C3 Epiglottis
Oropharynx becomes laryngopharynx T11 Lowest extent of lungs (inferolateral angles of
posterior aspects of lungs)
C3 disc Common carotid arteries split into internal Inferior extent of esophagus
and external carotid arteries Cardiac orifice of stomach
Carotid sinus Left suprarenal gland
C3 spinous Greater cornua of hyoid bone T12 Aortic hiatus (diaphragm)
C4 disc Laryngeal prominence Costodiaphragmatic recesses
C5 Vocal folds Inferior pole of spleen
Erb’s point Tail of pancreas
Superior margin of lobes of thyroid gland Orifice of gallbladder
Superior poles of kidneys (right slightly lower
C6 Middle cervical ganglion than left)
Cricoid cartilage Right suprarenal gland
First tracheal ring
Transition of larynx to trachea L1 Pyloric orifice of stomach
Transition of laryngopharynx to esophagus Superior horizontal (first) part of duodenum
Left colic (splenic) flexure
C7 Inferior cervical ganglion
L1 disc Transpyloric plane
T1 Stellate ganglion Conus medullaris
Inferior margin of thyroid gland Hila of kidneys (right slightly below and left
Subclavian and internal jugular veins unite to slightly above)
form brachiocephalic veins
Apices of lungs L2 Duodenal-jejunal junction
Right colic (hepatic) flexure
T2 Brachiocephalic veins unite to form superior Head of pancreas
vena cava
L3 Subcostal plane (lowest portion of costal
T2 disc Suprasternal notch margin made up from the tenth costal
T4 Aortic arch cartilage)
T4 disc Sternal angle (of Louis) Umbilicus (inconsistent)
Inferior horizontal (third) part of duodenum
T5 Pulmonary trunk divides into right and left Right extent of lower border of liver
pulmonary arteries Inferior poles of kidneys (right slightly lower
Pulmonary artery and primary bronchus enter than left)
right lung
Trachea divides into primary bronchi L4 Beginning of sigmoid colon
Aorta divides into common iliac arteries
Posterosuperior ends of oblique fissures of
lungs L5 Common iliac veins unite to form inferior vena
cava
T6 Base of heart
Ileocecal junction
Pulmonary artery and primary bronchus enter
Vermiform appendix arises from cecum
left lung
Pulmonary veins exit right lung L5 disc Anterior superior iliac spine
Superior vena cava enters right atrium Superolateral end of inguinal ligament
T7 Pulmonary veins exit left lung S3 Beginning of rectum
Inferior vena cava enters right atrium
Horizontal fissure of right lung Lower sacrum Superior extent of uterus

T8 Caval hiatus (diaphragm) Coccyx Pubic crest

Superior extent of right hemidiaphragm Ganglion impar
Superior border of liver Superior margin of pubic symphysis
Inferomedial end of inguinal ligament
T9 Xiphisternal junction Bladder (empty)
Fifth costal cartilage
8
 Chapter 1 – Surface Anatomy of the Back and Vertebral Levels of Clinically Important Structures
Clinical Anatomy of the Spine, Spinal Cord, and ANS

space. The sternal angle (of Louis) at the inferior margin of

Vertebral Levels of Structures in the Anterior
Neck and Trunk
This section describes the vertebral levels of most of the clin-
ically important structures found in the anterior neck and
trunk. Knowledge of the surface locations for the deep struc-
tures of the anterior neck and trunk is essential for relating
those structures to the whole person, especially during the
physical examination. This information is summarized in
Table 1-1.
Visual Landmarks
The most obvious visible structure in the anterior neck
region is the laryngeal prominence (Fig. 1-5). It can be seen
in the midline at the level of the C4 disc and is larger in adult
men than in women. Moving inferiorly, the jugular notch
(or incisure) of the sternum, or suprasternal notch, is at the
superior margin of the manubrium and corresponds with
the horizontal plane of the T2 disc or T1-2 interspinous
the manubrium is at the level of the T4 disc. Near the infe-
rior end of the sternum the xiphisternal junction is found.
It corresponds not only with the body of T9 but also with
the inferior margin of the pectoralis major muscle and the
fifth costal cartilages. These relationships are quite variable
depending on body type. Laterally, the lowest portion of the
costal margin consists of the tenth costal cartilages. The hori-
zontal plane at this level is termed the subcostal plane and
passes through the body of L3 (Moore & Dalley, 2006).
The transpyloric plane is the horizontal plane at the half-
way point between the upper border of the symphysis pubis
and suprasternal notch. It corresponds with the L1 disc and
usually is one hand breadth (10 cm) inferior to the xiphi-
sternal junction. The vertebral level of the umbilicus is typi-
cally at the level of L3, but this varies depending on body
type and weight. The pubic crest is identified with the level
of the superior margin of the pubic symphysis. It extends 2.5
cm lateral to the midline and has a prominence on its lateral

Laryngeal prominence

Jugular notch of sternum

1
2

Sternal angle 3

Pectoralis major m. 5

7
Xiphisternal junction
8
A
9
10 B
Anterior superior iliac spine

Inguinal ligament

Pubic tubercle

FIG. 1-5 Visual landmarks of the anterior trunk. A, The transpyloric plane. B, The subcostal plane. Note that the ribs have
been numbered.

9
PART ONE
Characteristics of the Spine and Spinal Cord
aspect known as the pubic tubercle. Typically the pubic crest
is in the same plane as the coccyx, but again weight and body
type can alter the tilt of the pelvis and therefore this relation-
ship. The inguinal ligament extends from the anterior supe-
rior iliac spine at the level of the L5 disc to the pubic tubercle
and demarcates the beginning of the thigh region.
Deeper Structures
Neural Structures. At the level of the atlas, the gross ana-
tomic transition of the medulla oblongata into the spinal
cord occurs as it exits the cranium via the foramen magnum.
The conus medullaris, the inferior tip of the spinal cord, usu-
ally is found at the L1-2 level (see previous discussion).
The sympathetic trunks (Fig. 1-6) extend along the entire
anterolateral aspect of the spinal column. In the cervical
region the trunks are approximately 2.5 cm lateral to the
midline. They are somewhat more laterally located in the
thoracic and lumbar regions. Along the anterior surface of
the sacrum the trunks begin to converge until they meet as
the ganglion impar on the anterior surface of the coccyx.
Sympathetic ganglia are located at fairly regular intervals
along these trunks. Typically there are three ganglia in the
cervical region (see Fig. 1-6). The superior cervical ganglion
can be found at the C2-3 interspace. The middle and inferior
cervical ganglia typically are found at the C6 and C7 levels,
respectively. Sometimes the inferior cervical ganglion and
Accessory n.
Superior cervical
ganglion
C3
C5
Middle cervical
ganglion
Stellate ganglion
FIG. 1-6 Erb’s point and the cervical sympathetic trunk. Note that Erb’s point is located midway along the posterior border of
the sternocleidomastoid muscle. Also note the sympathetic trunk connecting the cervical sympathetic ganglia.
10
first thoracic ganglion unite to form the stellate (or cervico-
thoracic) ganglion, which is found at the T1 level. The sym-
pathetic trunks are described in more detail in Chapters 5-8
and 10.
Several peripheral nerves become superficial approxi-
mately midway along the posterior border of the SCM (see
Fig. 1-6). This area is sometimes called Erb’s point and is
approximately at the C5 level. These nerves include the trans-
verse cervical nerve, which supplies the skin of the throat
region; the lesser occipital nerve, which innervates the skin
in the area of the mastoid process; and the great ­auricular
nerve, which innervates the skin in the vicinity of the ear. In
addition, the supraclavicular nerves arise by a common trunk
that emerges from Erb’s point. This trunk divides into three
branches that either are called anterior, middle, and pos-
terior or are named medial, intermediate, and lateral; they
course through the skin of the upper chest region. Finally,
the accessory nerve (cranial nerve XI) becomes relatively
superficial in this region after sending motor branches into
the deep surface of the SCM. It then courses in a posterolat-
eral direction, across the posterior triangle of the neck, to
reach the deep surface of the trapezius muscle, which it also
supplies with motor innervation.
The roots of the brachial plexus, which arise from the ven-
tral rami of the C5-T1 spinal nerves, are located just poste-
rior to the lower one third of the SCM (Keogh & Ebbs, 1984).
Lesser occipital n.
C1
Great auricular n.
C2
Transverse cervical n.
C4
Supraclavicular nn.
(anterior, middle,
posterior)
 Chapter 1 – Surface Anatomy of the Back and Vertebral Levels of Clinically Important Structures
Clinical Anatomy of the Spine, Spinal Cord, and ANS

The upper (or lateral) margin of the plexus runs along a line
from the junction of the middle and lower thirds of the SCM
to the tip of the coracoid process of the scapula. The lower
(or medial) border of the plexus extends from the junction
of the posterior border of the SCM with the clavicle to one
finger breadth (2 cm) inferior and medial to the tip of the
coracoid process of the scapula.
Vascular Structures. The shape of the heart may be
thought of as an isosceles triangle with a superior base and
an inferior apex directed to the left of the midline (Fig. 1-7).
The base of the heart usually can be found at the level of T6.
The horizontal position of the apex of the heart typically is
said to be at the level of T10, but this is variable depending
on the patient’s body type. It may be found as high as T9

C1

C7

Hyoid bone

Cricoid cartilage

T5

Transverse fissure Heart

of right lung

Liver T10
Spleen

L1
Duodenum
L1
Kidney
Transverse
colon
Abdominal aorta

Descending
colon
Terminal ileum L5

L5

Bladder

FIG. 1-7 Vertebral levels of deeper structures of the anterior neck and trunk.

11
PART ONE
Characteristics of the Spine and Spinal Cord
(Moore & Dalley, 2006) or as low as T11 (Gardner, Gray, &
O’Rahilly, 1975).
The ascending aorta emerges from the left ventricle of the
heart approximately in the midline and runs superiorly. It
then turns to the left and forms the aortic arch that can be
found at the level of the T4 body. The thoracic portion of
the descending aorta begins in the plane of the T4 disc and
runs inferiorly slightly left of the midline along the anterior
surface of the thoracic vertebrae. It becomes the abdominal
aorta as it passes through the aortic hiatus of the diaphragm
in the midline at the level of T12 (Moore & Dalley, 2006). The
abdominal aorta descends along the anterior surface of the
lumbar vertebrae and divides into the common iliac arteries
just anterior to the L4 body, slightly left of the midline.
The aortic arch has three branches. The first is the bra-
chiocephalic trunk. This trunk gives rise to the right com-
mon carotid and right subclavian arteries. The left common
carotid artery is the second branch of the aortic arch, and
the left subclavian artery is the third branch of the aortic
arch. The subclavian arteries supply blood to the upper
extremities, and the common carotid arteries supply the
head and neck region. The common carotid arteries ascend
on either side of the anterolateral aspect of the neck to the
level of the C3 disc, where they each split into an internal
and external carotid artery. This is the region of the impor-
tant carotid sinus, which monitors the blood pressure of
the body. Therefore care must be taken when palpating
these structures, and they should always be palpated only
unilaterally.
The pulmonary trunk arises from the right ventricle of
the heart and divides into the right and left pulmonary arter-
ies in a plane with T5. The pulmonary arteries enter (and the
pulmonary veins exit) their respective lungs via a hilum. The
pulmonary artery of the right lung enters in the plane of T5
and that of the left lung at the level of T6 (Standring et al.,
2008). The pulmonary veins exit the lungs approximately
one vertebral level lower than the arteries enter. There is
some variation of these levels with body type, and both of
the pulmonary arteries may enter their respective lungs as
low as T7 (Gardner, Gray, & O’Rahilly, 1975).
The internal jugular and subclavian veins of each side of
the body unite several centimeters lateral to the midline at
the level of T1 to form the brachiocephalic veins. The bra-
chiocephalic veins then unite to form the superior vena cava
slightly right of the midline at the T2 level (Standring et al.,
2008). The superior vena cava courses inferiorly and ends in
the upper portion of the right atrium of the heart at approxi-
mately the level of T6.
The common iliac veins unite to form the inferior vena
cava at the level of the L5 body, a little to the right of the
midline. The inferior vena cava then ascends in front of the
vertebral column, on the right side of the abdominal aorta.
Passing through the caval hiatus of the diaphragm in the
horizontal plane of the body of T8 (Moore & Dalley, 2006),
the inferior vena cava enters the lower portion of the right
atrium just above that level at T7.
12
Visceral Structures. The respiratory system begins with the
nasal cavity, which is separated from the oral cavity by the
hard palate. The hard palate lies in the same horizontal plane
as the atlas. The nasal cavity becomes continuous with the
nasopharynx in the region of the soft palate also at the level
of C1. The nasopharynx joins the oropharynx at the inferior
border of the posterior margin of the soft palate just anterior
to the C2 body, and for several centimeters the alimentary
and respiratory systems share a common passageway. At the
superior border of the epiglottis, the oropharynx becomes
the laryngopharynx. In this region the alimentary and respi-
ratory tracts again become separate. Anteriorly the respi-
ratory tract continues as the larynx. Its lumen is protected
during deglutition by the epiglottis, which may be found
at the C3 level. The adjacent hyoid bone provides attach-
ment sites for several muscles involved in deglutition and
vocalization, and its greater cornua can be found at the C3
spinous process level. The most anterior projection of the
thyroid cartilage, the laryngeal prominence, is at the level of
the C4 disc, and the vocal folds, or cords, are slightly lower
in the C5 plane. The cricoid cartilage, the lowest portion of
the ­larynx, joins the first tracheal ring, the highest portion of
the trachea, at the level of C6. The lobes of the thyroid gland
are located anterior and lateral to the larynx and trachea and
extend from the C5 to T1 levels. The trachea descends in the
midline anterior to the esophagus to the level of the upper
border of the T5 body, where it divides into the primary
bronchi (Standring et al., 2008). The primary bronchi enter
the lungs via their respective hila at around the same levels
as the pulmonary arteries, which are T5 on the right and T6
on the left.
The apex of each lung extends superiorly to the level of
the T1 body (see Fig. 1-7). On their posterior aspects, the
inferomedial angles of both lungs are approximately at T9,
and the inferolateral angles, the lowest portion of the lungs,
extend inferiorly to near T11. The anteroinferior border of
each lung is approximately one vertebral level higher than
the posterior border. With full inspiration these levels may
descend nearly two vertebral segments (Standring et al.,
2008).
The left lung is divided into upper and lower lobes by an
oblique fissure. This fissure extends from the T5 level pos-
terosuperiorly to T10 anteroinferiorly. The right lung not
only has an oblique fissure similar to that of the left lung,
but also has a horizontal fissure at the level of T7. Therefore
the right lung is divided into three lobes: upper, middle, and
lower.
The diaphragm extends several vertebral levels superiorly
in its center and is shaped like a dome. Therefore the dia-
phragm makes an impression on the inferior surface of each
of the lungs. The right half of the diaphragm, often termed
the right hemidiaphragm, reaches the T8 level and because
of the underlying liver is approximately 1 cm higher than
the level of the left hemidiaphragm (Moore & Dalley, 2006).
With full inspiration, these levels may descend as much
as two vertebral levels (Standring et al., 2008). Normally
 Chapter 1 – Surface Anatomy of the Back and Vertebral Levels of Clinically Important Structures
the pleural cavity extends slightly lower than the inferolat-
eral angles of the lungs and forms the costodiaphragmatic
recesses at the level of T12. Because of the domelike shape of
the diaphragm, these recesses represent the lowest points of
the thoracic cavity and are potential sites of fluid accumula-
tion in the chest.
The alimentary canal begins as the oral cavity, which
becomes the oropharynx in the region of the soft palate at
the C1 level. The oropharynx, after being joined by the naso-
pharynx at the inferior border of the free edge of the soft
palate just in front of the C2 body, turns into the laryngo-
pharynx at the superior border of the epiglottis at the level
of C3. The laryngopharynx continues inferiorly on the pos-
terior aspect of the larynx and changes into the esophagus
at the level of C6. The esophagus runs inferiorly in the chest
on the anterior aspect of the vertebral column slightly ante-
rior and to the right of the descending thoracic aorta. Passing
through the diaphragm via the esophageal hiatus at the T10
level, the esophagus enters the abdomen (Standring et al.,
2008) and ends at the cardiac orifice of the stomach slightly
left of the midline at T11.
The stomach is the most dilated portion of the alimen-
tary canal. Curving inferiorly and to the right, the stomach
becomes continuous with the small intestine at the pyloric
orifice at the level of L1. The duodenum, the first part of
the small intestine, is shaped like a U lying on its side and
has four parts. The first (superior horizontal) part contin-
ues from the pyloric orifice horizontally to the right at the
level of L1. The second (descending) part proceeds inferiorly
to the horizontal plane of L3, where it turns to the left to
become the third (inferior horizontal) part. The third part
continues to the left, crosses the midline, and bends slightly
superiorly to give rise to the fourth (ascending) part that
runs obliquely superior and ends as the duodenal-jejunal
junction at the level of L2.
The rest of the small intestine continues as a series of
loops and ends by connecting with the large intestine at
the ­junction of the cecum and the ascending portion of the
colon in the right lower quadrant of the abdomen at the L5
level. The proximal (oral) two fifths and the distal (aboral)
three fifths of the small intestine distal to the duodenum are
called the jejunum and ileum, respectively.
The large intestine begins as the cecum, which is a cul-de-
sac located in the right iliac fossa (see Fig. 1-7). The ileum
connects with the upper portion of the cecum at the L5 level.
The vermiform appendix usually arises from the cecum
approximately one finger breadth (2 cm) inferior to the ileo-
cecal junction. The large intestine continues in a superior
direction above the ileocecal junction as the ascending colon.
At the level of L2 the ascending colon makes a sharp turn to
the left and continues as the transverse colon. This sharp turn
is termed the right colic, or hepatic, flexure, because it is just
below the liver. The transverse colon continues horizontally
and slightly superiorly across the midline to the left side of
the abdomen, where it turns sharply inferior. This left colic
flexure occurs at the L1 level, which is slightly more superior
Clinical Anatomy of the Spine, Spinal Cord, and ANS
than the right colic flexure. The left colic flexure, located just
below the spleen, sometimes is termed the splenic flexure.
The large intestine then continues inferiorly on the left side
of the abdominal cavity as the descending colon. At the L4
level, the large intestine becomes somewhat tortuous and is
called the sigmoid colon. The sigmoid colon then continues
into the true pelvis and becomes the rectum in the midline
at the S3 level.
The head of the pancreas can be found within the curve
of the duodenum. Usually it is described as being located at
the level of L2 (Standring et al., 2008). The neck and body of
the pancreas extend superiorly and obliquely to the left. The
body of the pancreas ends as the tail of the pancreas, which
can be found at the lower pole of the spleen in the left upper
quadrant at T12. The superior pole of the spleen is adjacent
to the left hemidiaphragm at approximately the level of T9.
The liver, the largest gland of the body, is found mostly
in the upper right quadrant of the abdomen, but its left lobe
does extend somewhat across the midline. Superiorly the
liver is in contact with the diaphragm and fills the domelike
hollow of the right hemidiaphragm. The superior border of
the liver therefore extends up to the T8 level. The inferior
border runs diagonally from the right side of the abdomen at
the level of L3 to the left hemidiaphragm at the T9 horizontal
plane (Standring et al., 2008). The gallbladder rests in a fossa
in the inferior border of the right lobe of the liver. The orifice
of the gallbladder is usually found at the T12 level.
The urinary system begins with the kidneys. The superior
poles of the kidneys lie at the level of T12 and their inferior
poles at L3. The right kidney is slightly lower than the left
kidney, probably because of its relationship with the liver
(Standring et al., 2008). The suprarenal, or adrenal, glands
are located on the anterosuperior borders of the kidneys. As
with the kidneys, the left suprarenal gland is located some-
what more superior than the right. These endocrine glands
can be found at the T11 and T12 levels, respectively. The
hilum of the left kidney is just above the level of the L1 disc
(transpyloric plane), and that of the right kidney just below
it. A ureter arises from the hilum of each kidney, and both
run to the bladder in an inferior and slightly medial direc-
tion. The bladder is a midline structure in the true pelvis
posterior to the pubic symphysis at the coccygeal level. The
bladder may expand upward and forward into the abdomi-
nal cavity when distended.
In the female the uterus lies posterior to the bladder and
anterior to the rectum. Superiorly the uterus extends above
the superior border of the bladder to the lower sacral levels,
and because of its anteverted and anteflexed position, the
superior portion of the uterus usually lies on the posterior
portion of the superior surface of the empty bladder. The
ovaries are situated with one ovary located on either side of
the uterus near the lateral wall of the true pelvis. The posi-
tion of the ovaries is variable, especially in parous women,
because they are displaced during a woman’s first preg-
nancy and probably never return to their original position
­(Standring et al., 2008).
13
PART ONE
Characteristics of the Spine and Spinal Cord
This chapter serves as a useful reference as the reader
progresses through the rest of this text. Knowledge of the
structures of the body that are visible and palpable through
the skin and an awareness of the surface locations of deeper
structures are important tools in the proper examination and
evaluation of patients. Therefore this chapter is designed not
only as a beginning reference point for the rest of the text,
but also as a quick reference for the health care provider.
REFERENCES
Byfield DC, Mathiasen J, & Sangren C. (1992). The reliability of osseous
landmark palpation in the lumbar spine and pelvis. Eur J Chiro, 40,
83-88.
Cooperstein R & Haneline MT. (2007). Spinous process palpation using
the scapular tip as a landmark vs a radiographic criterion standard.
J Chiropr Med, 6(3), 87-93.
Cooperstein MA, Haneline MT, & Young MD. (2009). The location of
the inferior angle of the scapula in relation to the spinal level of prone
patients. J Can Chiropr Assoc, 53(2), 121-128.
Downey BJ, Taylor NF, & Nierce KR. (1999). Manipulative physiothera-
pists can reliably palpate nominated lumbar spinal levels. Manipulative
Ther, 4, 351-356.
14
Fitzgerald MJT. (1985). Neuroanatomy basic & applied. London: Baillière
Tindall.
Gardner E, Gray DJ, & O’Rahilly R. (1975). Anatomy. Philadelphia:
WB Saunders.
Haneline MT et al. (2008). Determining spinal level using the inferior
angle of the scapula as a reference landmark: a retrospective analysis of
50 radiographs. J Can Chiropr Assoc, 52(1), 24-29.
Keogh B & Ebbs S. (1984). Normal surface anatomy. London: William
Heinemann Medical Books.
Moore KL & Dalley AF. (2006). Clinically oriented anatomy (5th ed.).
Philadelphia: Lippincott Williams & Wilkins.
Oliver J & Middleditch A. (1991). Functional anatomy of the spine. Oxford,
UK: Butterworth-Heinemann.
Phillips DR et al. (2009). Simple anatomical information improves the
accuracy of locating specific spinous processes during manual examina-
tion of the low back. Man Ther, 14(3), 346-350.
Pysyk CL et al. (2010). Ultrasound assessment of the vertebral level of the
palpated intercristal (Tuffier’s) line. Can J Anaesth, 57(1), 46-49.
Sadler TW. (2010). Langman’s medical embryology (11th ed.). Philadelphia:
Lippincott Williams & Wilkins.
Standring S et al. (2008). Gray’s anatomy: the anatomical basis of clinical
practice (40th ed.). Edinburgh: Churchill Livingstone.
Stonelake PS, Burwell RG, & Webb JK. (1988). Variation in vertebral levels
of the vertebra prominens and sacral dimples in subjects with scoliosis.
J Anat, 159, 165-172.
Chapter 2
General Characteristics
of the Spine
Gregory D. Cramer
Function and Development of the Spine, 15
Development of the Spine, 15
Curves of the Spine, 16
Anatomy of a Typical Vertebra, 18
Vertebral Body, 19
Vertebral Arch, 24
Functional Components of a Typical Vertebra, 25
Zygapophysial Joints, 25
Movement of the Spine, 32
The Role of Spinal Ligaments, 32
Structures That Limit Spinal Movement, 35
Rotation with Lateral Flexion (“Coupled Motion”), 35
Interbody Joint and Intervertebral Disc, 35
Composition of the Intervertebral Disc, 37
Clinical Implications Related
to the Intervertebral Disc, 39
Nucleus Pulposus, 40
Vertebral (Cartilaginous) End Plates, 42
Innervation of the Intervertebral Discs, 43
Relationship of the Spinal Nerves
to the Intervertebral Disc, 43
Syndesmoses of the Spine, 44
Vertebral Canal, 45
External Vertebral Venous Plexus, 46
Epidural Space, 46
Internal Vertebral Venous Plexus, 47
Meningeal and Neural Elements within the Vertebral
Canal, 48
Arterial Supply to the Spine, 48
Intervertebral Foramen, 49
Accessory Ligaments of the Intervertebral Foramen, 53
Advanced Diagnostic Imaging of the Spine, 55
Magnetic Resonance Imaging, 57
Computed Tomography, 59
Other Imaging Modalities, 60
The purpose of this chapter is to discuss the basic and clinical
anatomy of the spine as a whole, that is, to introduce many
of the features that are common to the major regions of the
spine (cervical, thoracic, and lumbar). Some of the topics
listed are discussed in more detail in later chapters.
Function and Development of the Spine
The anatomy of the human spine can be understood best if
its functions are considered first. The spine has three primary
functions: support of the body, protection of the spinal cord
and spinal nerve roots, and movement of the trunk. The
vertebral column has the ideal structure to carry out all of
these functions simultaneously (Putz & Müller-Gerbl, 1996).
These varied functions are performed by a series of movable
bones, called vertebrae, and the soft tissues that surround
these bones. A brief explanation of the development of the
vertebrae and the related soft tissues is given to highlight the
detailed anatomy of these structures. A more thorough dis-
cussion of spinal development is presented in Chapter 12.
Development of the Spine
After the early development of the neural groove into the neu-
ral tube and neural crest (see Fig. 12-7), paraxial mesoderm
condenses to form somites (see Figs. 12-7 and 12-9, A). The
somites, in turn, develop into dermomyotomes and sclero-
tomes. Portions of the lateral aspects of the dermomyotomes
develop into the dermis and subcutaneous tissue, whereas the
majority of the dermomyotomes develop into the axial mus-
culature. The sclerotomes migrate centrally to surround the
neural tube and notochord (see Fig. 12-9, B). The sclerotomal
cells then form the vertebral column and associated ligaments.
While the paraxial mesoderm is developing into somites,
the more inferior portion of the neural tube differenti-
ates into the ependymal, mantle, and marginal layers of
the future spinal cord. The ependymal layer surrounds the
future central canal region of the spinal cord. The mantle
layer develops into the cells of the nervous system (neurons
and glia), and the outer marginal layer of the tube consists
of the axons of tract cells. The neural crest develops into the
sensory neurons of the peripheral nervous system and the
postganglionic neurons of the autonomic nervous system.
15
PART ONE
Characteristics of the Spine and Spinal Cord
Chondrification Centers and Primary Ossification
­Centers. Cells of sclerotomal origin condense to form ver-
tebral chondrification centers (one pair in the anterior aspect
and at least one center in each half of the posterior aspect of
the mesenchymal vertebrae). This results in the development
of a cartilage model of each vertebra (see Fig. 12-11). Each ver-
tebra then develops three primary centers of ossification (see
Fig. 12-11). One primary center is located in the anterior part
of the future vertebra. This region is known as the centrum
and helps to form the future vertebral body. The remaining
two primary ossification centers are located on each side of
the portion of the vertebra that surrounds the developing
neural tube. This region is known as the neural or posterior
arch. The two ossification centers at the neural arch normally
unite posteriorly to form the spinous process. Failure of these
centers to unite results in a condition known as spina bifida.
This condition is discussed in more detail in Chapter 12.
Anteriorly the left and right sides of the neural arch normally
fuse to the centrum. Known as the neurocentral synchondrosis,
this region actually is located within the area that becomes the
posterior aspect of the vertebral body. The fusion that occurs
unites the primary ossification centers of the neural arch with
the centrum, consequently forming a vertebral body from both
the centrum and a small part of the neural arch. Because of this
unique fusion the vertebral arch is somewhat smaller than its
developmental predecessor, the neural arch, and the vertebral
body is somewhat larger than its predecessor, the centrum.
The precise time of fusion between the neural arch and
centrum at the neurocentral synchondrosis remains a topic of
investigation. Some researchers state that closure occurs by 6
years of age (Maat et al., 1996), and other investigators claim
that the neurocentral cartilage may remain until as late as 16
years of age (Vital et al., 1989). Part of the function of the neu-
rocentral cartilage is to ensure growth of the posterior arch of
the vertebrae. Early fusion of the neurocentral synchondro-
sis has been implicated in the development of scoliosis (Vital
et al., 1989). Scoliosis is discussed in more detail in Chapter 6.
Usually the vertebral body develops from two centers of
chondrification, left and right. If one of these centers fails to
develop, only one half of the vertebral body remains. This
is known as a hemivertebra, or cuneiform vertebra, and can
result in lateral curvature of the spine. Frequently a hemiver-
tebra at one level is compensated by the same condition at
another level on the opposite side.
During development the vertebral bodies may appear to
be wedge shaped, narrower anteriorly than posteriorly. This
can give the appearance of a compression fracture (Fesmire
& Luten, 1989). Wedging that occurs in several consecutive
vertebrae is seen as an indication of a normal variant. How-
ever, a compression fracture of the wedge-shaped vertebra
must be considered if it occurs at only one level and the ver-
tebrae above and below are more rectangular in appearance.
Secondary Ossification Centers. Five secondary centers of
ossification appear in the vertebral column between the ages of
10 and 13 (see Fig. 12-11). One secondary center of ossification
16
is located on each of the cartilaginous end plates of a typical
vertebral body. These centers are known as the anular apophy-
ses (singular, apophysis), ring apophyses, or anular epiphyses
(Standring et al., 2008). A secondary center of ossification also is
found on the tips of each of the transverse processes, and another
is located on the tip of the single spinous process. The centers on
the transverse processes and spinous process enable the rapid
growth of these processes that occurs during adolescence.
The two centers of ossification associated with the
peripheral rim of the upper and lower surfaces of the ver-
tebral bodies (anular apophyses) do not help with the lon-
gitudinal growth of the vertebral bodies and for this reason
are termed ring apophyses (Theil, Clements, & Cassidy, 1992;
Bogduk, 2005a). These centers incorporate the outer layers
of the anulus fibrosus (Fardon, 1988), which explains the
bony attachment of the outer layers of the anulus, whereas
the more central layers are attached to the cartilage of the
vertebral end plates (Bogduk, 2005a).
All of the secondary ossification centers listed previously
fuse with the remainder of the vertebrae between the ages
of 14 and 25 (Bogduk, 2005a; Standring et al., 2008), and
no further growth can occur after their fusion. These centers
can be mistaken as sites of fracture before they have fused.
Fully Developed Vertebral Column. The first accurate
description of the number of movable vertebrae in the fully
developed spine was that of Galen between 100 and 200 ad
(Shapiro, 1990). However, perhaps because of the many ana-
tomic errors made by Galen in other areas, controversy ensued
over the precise number of vertebrae until the publication
of Vesalius’ De Humani Corporis Fabrica in 1543 (Shapiro,
1990). This publication showed that the human vertebral col-
umn develops into 24 vertebrae (Fig. 2-1), which are divided
into 7 cervical, 12 thoracic, and 5 lumbar vertebrae (expressed
as C1-7, T1-12, and L1-5, respectively). The L5 vertebra rests
on the bony sacrum (made of five fused segments). The coc-
cyx (three to five fused segments) is suspended from the
sacrum. All of these bones are joined by means of a series of
approximately 361 joints (including synovial, symphyses, and
syndesmoses; and including the joints between the vertebrae
and ribs and the joints associated with the sacrum and the
coccyx) to form the vertebral column. See Appendix I for a
detailed list of the joints of the vertebral column.
Curves of the Spine
The spine develops four anterior to posterior curves, two
kyphoses, and two lordoses. (See introduction of text for
further clarification of the terms lordosis and kyphosis.)
Kyphoses are curves that are convex posteriorly (concave
anteriorly), and lordoses are curves that are convex anteri-
orly (concave posteriorly). The two primary curves are the
kyphoses. These include the thoracic and pelvic curvatures
(see Fig. 2-1). They are called primary curves because they
are seen from the earliest stages of fetal development. The
thoracic curve extends from T2 to T12 and is created by the

larger superior to inferior dimensions of the posterior por-
tion of the thoracic vertebrae (see Chapter 6). The pelvic
curve extends from the lumbosacral articulation throughout
the sacrum to the tip of the coccyx. The concavity of the pel-
vic curve faces anteriorly and inferiorly, and is also caused by
the greater superior to inferior dimensions of the posterior
portion of the sacral segments.
The two secondary curves are the cervical lordosis and lum-
bar lordosis (see Fig. 2-1). These curves are known as second-
ary or compensatory curves because, even though they can be
detected during fetal development, they do not become appar-
ent until the postnatal period. The cervical lordosis begins
late in intrauterine life but becomes apparent when an infant
begins to lift his or her head from the prone position (approxi-
mately 3 to 4 months after birth). This forces the cervical spine
into a lordotic curve. The cervical lordosis is further accentu-
ated when the small child begins to sit upright and stabilizes
his or her head while looking around in the seated position.
Cervical
region
Thoracic
region
Lumbar
region
Sacrum
Coccyx
A B
FIG. 2-1 Three views of the vertebral column. A, Lateral view showing the cervical, thoracic, lumbar, and sacral
regions. Also notice the cervical and lumbar lordoses and the thoracic and sacral kyphoses. B, Anterior view.
Chapter 2 – General Characteristics of the Spine
Clinical Anatomy of the Spine, Spinal Cord, and ANS
This occurs at approximately 9 months of age. In the adult, the
cervical curve is maintained by the larger superior to inferior
dimensions of the anterior portion of the intervertebral discs.
Because this curve is primarily created by the pliable interver-
tebral discs, traction of the cervical region reduces the cervical
lordosis, whereas traction to the thoracic region has little effect
on the thoracic kyphosis, because the thoracic curve is primar-
ily created by the shape of the vertebrae. Further details of the
cervical curvature are given in Chapter 5.
The action of the erector spinae muscles (see Chapter 4),
pulling the lumbar spine erect to achieve the position neces-
sary for walking, creates the posterior concavity known as the
lumbar lordosis (see Fig. 2-1). Therefore the lumbar lordosis
develops approximately 9 to 18 months after birth while the
infant begins to walk upright. The lumbar lordosis extends
from T12 to the lumbosacral articulation and is more pro-
nounced in females than in males. The region between L3
and the lumbosacral angle is more prominently lordotic than
C7
T5
T12
L3
L5
Sacrum
Coccyx
Continued
17
PART ONE
Characteristics of the Spine and Spinal Cord
C1
C7
T1
T12
L5
Sacrum
Coccyx
C the lines of greatest stress (Skedros, Mason, & Bloebaum, 1994;
FIG. 2-1, cont’d C, Posterior view of the vertebral column.
the region from T12 to L2. After infancy, the lumbar lordosis
is maintained by a combination of the shape of the interverte-
bral discs and the shape of the vertebral bodies. Each of these
structures is taller anteriorly than posteriorly in the lumbar
region of the spine. Therefore the lumbar lordosis is reduced
when traction forces are applied to it, but the reduction is less
than that found during traction of the cervical region.
A slight lateral curve normally is found in the upper thoracic
region. The convexity of the curve is on the left in left-handed
people and on the right in right-handed people. Such deviations
are probably the result of asymmetric muscle use and tone.
The lumbar lordosis and thoracic kyphosis both increase
from the supine to the standing position (Wood et al., 1996).
In addition, the cervical lordosis has been found to compensate
for the variations in lumbar lordosis that occur during changes
in position and during normal motion. For example, lumbar
lordosis increases during sitting in the erect position and cer-
vical lordosis decreases during this activity. Lumbar lordosis
decreases during lumbar forward flexion and cervical lordosis
18
increases during lumbar flexion, and the opposite occurs dur-
ing lumbar extension (Black, McClure, & Polansky, 1996).
The kyphoses and lordoses of the spine, along with the inter-
vertebral discs, help to absorb the loads applied to the spine.
These loads include the weight of the trunk, along with loads
applied through the lower extremities during walking, run-
ning, and jumping. In addition, loads are applied by the carry-
ing of objects with the upper extremities, by the pull of spinal
muscles, and by the wide variety of movements that normally
occur in the spine. The spinal curves, acting with the interver-
tebral discs and vertebral bodies, dissipate the increased loads
that would occur if the spine were shaped like a straight col-
umn. Yet even with these safeguards, the vertebrae can be frac-
tured as a result of the person falling and landing on the feet or
buttocks, objects falling and landing on the head, or the person
diving and landing on the head. Such injuries usually com-
press the vertebral bodies. Cervical compression usually occurs
between C4 and C6 (Croft, 2009). When the force emanates
from below, T9 through L2 are the most commonly affected
through compression. Flexion injuries also can result in a com-
pression fracture of vertebral bodies. Again, C4 through C6 are
the most commonly affected in the cervical region, whereas T5
and T6 and the upper lumbar vertebrae usually are affected in
the thoracic and lumbar regions (White & Panjabi, 1990).
Anatomy of a Typical Vertebra
A typical vertebra can be divided into two basic regions: a ver-
tebral body and a vertebral arch (also called the posterior arch
or dorsal arch). The bone in both regions is composed of an
outer layer of compact bone and a core of trabecular bone, also
known as cancellous, or spongy, bone (Fig. 2-2). The cancellous
bone is composed of myriad spicules of bone, known as trabec-
ulae (singular, trabecula). The trabeculae are oriented parallel to
Skedros et al., 1994). Smit and colleagues (1997) found that
the trabecular architecture of the lumbar vertebral bodies was
ideal for the loads placed on the spine during axial compression
(loads placed on the vertebral bodies from above; for example,
to resist gravity) and walking. That is, not only were the tra-
beculae arranged to withstand axial compression, but also they
were quite strong where the pedicles of the posterior arch met
the vertebral bodies. This latter finding is consistent with the
transfer of loads from the articular processes of the posterior
arch to the vertebral bodies during rotational movements in the
horizontal plane, and anterior to posterior (“shearing”) move-
ments (most closely associated with walking).
The shell of compact bone is thin on the discal surfaces of the
vertebral body and is thicker in the vertebral arch and its pro-
cesses. The outer compact bone is covered by a thin layer of peri-
osteum that is innervated by nerve endings, which transmit both
nociception and proprioception (Edgar & Ghadially, 1976). The
outer compact bone also contains many small foramina to allow
passage for numerous veins and nutrient arteries. The trabecular
interior of a vertebra contains red marrow and the vertebral bod-
ies contain one or two large canals for the basivertebral vein(s).

Channel for
Cortical bone basivertebral vein
Cancellous bone
A Elaboration on each component of the vertebra, with special
B (Feltrin et al., 2001). The vertebral bodies are connected to
FIG. 2-2 Midsagittal view of a vertebra. A, The central cancellous,
or trabecular, bone of the vertebral body and spinous process. Also
notice the more peripheral cortical bone. B, The pattern of trabecu-
lation, which develops along the lines of greatest stress.
The density of bone in the vertebrae varies from indi-
vidual to individual but seems to increase significantly in
most people during puberty and reaches a peak during the
mid-twenties, when closure of the growth plates of the sec-
ondary centers of ossification occurs (Gilsanz, 1988; Gilsanz
et al., 1988). A decrease in bone mineral density to below
normal limits is known as osteoporosis. Osteoporosis also is
accompanied by a rearrangement of the trabeculae within the
spongy bone (Feltrin et al., 2001). This condition is of par-
ticular clinical relevance in the spine because of the weight-
bearing function of this region. A decrease in bone mineral
density and a rearrangement of trabeculae lead to a loss of
elasticity in the bone and an increase in bone fragility. These
changes, in turn, increase the likelihood of vertebral fracture
(Mosekilde & Mosekilde, 1990; Feltrin et al., 2001). Osteopo-
rosis has been associated with aging (Mosekilde & Mosekilde,
1990) and particularly with menopause (Ribot et al., 1988).
Ribot and colleagues (1988) found that spinal bone density in
French women remained stable in the young adult years and in
women more than 70 years of age. An average rate of apparent
bone loss of approximately 1% per year was found between
the ages of 45 and 65. This represented approximately 75%
of the total bone loss occurring within the individuals of their
sample population (510 women). Ribot and colleagues (1988)
also found that the bone mineral density in their population
of French women appeared to be between 5% and 10% lower
Chapter 2 – General Characteristics of the Spine
Clinical Anatomy of the Spine, Spinal Cord, and ANS
than reported values in the United States. Mosekilde and
Mosekilde (1990), studying the L2 and L3 vertebrae, found
relatively few sex-related differences in vertebral body density.
However, Mosekilde (1989) did find a sex-related difference
in vertebral trabecular architecture with age. Consistent with
the findings of Ribot and colleagues (1988), Mosekilde (1989)
discovered that in both sexes bone density diminished by 35%
to 40% from 20 to 80 years of age. She also determined that
the trabecular center (cancellous bone) of the vertebral body
lost more bone mass than the outer cortical rim.
The regions of the vertebral body and vertebral arch are
discussed separately in the following sections of this chapter.
emphasis placed on the characteristics unique to each region
of the vertebral column, is included in the chapters on the
cervical, thoracic, and lumbar regions of the spine (Chapters
5 through 7). In addition, Table 2-1 compares and contrasts
the different parts of cervical, thoracic, and lumbar vertebrae.
Vertebral Body
The vertebral body (Fig. 2-3) is the large anterior portion
of a vertebra that acts to support the weight of the human
frame. Each vertebral body is designed to provide the great-
est amount of strength with the least amount of bone mass
one another by fibrocartilaginous intervertebral discs, and
when the bodies are combined with their intervening discs,
they create a flexible column or pillar that supports the
weight of the trunk and head. The vertebral bodies also must
be able to withstand additional forces from contraction of
the axial and proximal limb muscles. The bodies are cylin-
dric in shape and have unique characteristics in each named
region of the spine. The transverse diameter of the vertebral
bodies increases from C2 to L3. This probably results from
the fact that each successive vertebral body carries a slightly
greater load. There is variation in the width of the last two
lumbar vertebrae, but the width steadily diminishes from the
first sacral segment to the apex (inferior tip) of the coccyx.
Vertical trabeculae predominate in the vertebral bodies.
The vertical trabeculae are supported by horizontal trabecu-
lae that function much like the struts or support beams in
the frame of a building. Animal studies have shown that both
the vertical and the horizontal trabeculae of a vertebral body
increase in number after prolonged (weeks) and increased
loading by superior-inferior compression (Issever et al., 2003).
Osteoporosis is associated with a decrease in mass primarily
of the horizontal trabeculae, leaving less support for the vertical
trabeculae when loads are placed on an osteoporotic vertebral
body. This lack of horizontal support results in a weakening
of the vertebral body beyond that anticipated by the percent
reduction in bone mineral content. In fact, a 25% reduction in
bone mass is accompanied by a 50% reduction in the ability of
a vertebral body to resist loads applied to the spine.
Bone mineral density can vary significantly from one ver-
tebra to another (Curylo et al., 1996). Although determining
the presence or absence of osteoporosis by means of x-ray
19
PART ONE
Characteristics of the Spine and Spinal Cord

Table 2-1 Regional General Characteristics of Typical Vertebrae

Structure
Body
Pedicles
Transverse processes
Articular processes
(orientation [facing] of
superior articular facet)
Laminae
Spinous process
Intervertebral foramina
Vertebral canal
Typical vertebrae
Cervical Thoracic Lumbar
Rectangular Heart-shaped Kidney-shaped
Uncinate processes Taller posterior than anterior Taller anterior than posterior
Costal demifacets
Small Large, stout Large, stout
Superior and inferior vertebral No superior vertebral notch Superior (small) and inferior
notches vertebral notches
Anterior and posterior tubercles Large Large
Foramen of transverse process Transverse costal facet
Posteriorly, superiorly, and medially Posteriorly, superiorly, and laterally Posteriorly and medially
45 degrees to vertical plane 30 degrees to vertical plane Biplanar
Within vertical plane
Short from superior-inferior Tall from superior-inferior Intermediate from superior-
inferior
Bifid Upper four: posteriorly directed Spatulated in shape
Middle four: long and inferiorly
directed
Lower four: lumbarlike
Oval-shaped: 35-50% filled with Inverted pear-shaped: one twelfth Inverted pear-shaped: one
spinal nerve filled with spinal nerve third filled with spinal nerve
Trefoil-shaped: largest of vertebral Round in shape: smallest of Trefoil-shaped: intermediate
column vertebral column in size between cervical
and thoracic
C3-6 T2-9 All

bone densitometry to measure bone mineral density is reli-
able, fractal analysis of the trabecular pattern within verte-
bral bodies as imaged by computed tomography (CT) also
shows promise (Kim and Nah, 2007).
The vertebral bodies have been found to change (remodel)
after degeneration of the intervertebral discs, by adding bone
to the region adjacent to the intervertebral disc. This addi-
tion of bone is known as subchondral sclerosis, and allows
the vertebral bodies to more effectively absorb the additional
compressive loads received by the vertebral bodies after
intervertebral disc degeneration (Moore et al., 1996a,b).
Mosekilde and Mosekilde (1990) found that the cross-
sectional area of vertebral bodies is larger in men than in
women. They also found that the cross-sectional area of
the vertebral body increases with age in men, but no similar
finding was discovered in women.
The superior and inferior surfaces of vertebral bodies
range from flat, but not parallel (Standring et al., 2008),
to interlocking (see Chapter 5). A raised, smooth region
around the edge of the vertebral body is formed by the anu-
lar apophysis. The superior and inferior surfaces of the verte-
bral body are rougher inside the anular apophyses.
Most vertebral bodies are concave posteriorly (in the trans-
verse plane), where they help to form the vertebral foramina.
Small foramina for arteries and veins appear on the front and
sides of the vertebral bodies. Posteriorly there are small arte-
rial foramina and one or two large, centrally placed foramina
for the exiting basivertebral vein(s) (Standring et al., 2008).
A series of relatively large arteries pierce the center of the
vertebral bodies along their entire circumference (Fig. 2-4).
On entering a vertebral body, these large nutrient arteries form
a dense plexus of arteries within the central horizontal plane
of the vertebral body. From this central plexus, many small
branches ascend and descend to reach the superior and infe-
rior margins of the vertebral bodies; these margins are adja-
cent to the cartilaginous end plates of the intervertebral discs.
Large numbers of small veins drain the superior and inferior
margins of the vertebral bodies. These very small veins enter
into large tributaries that are oriented in the horizontal plane
very close to each superior and inferior vertebral margin. These
large tributaries have been called the horizontal subarticular
collecting vein system (Crock & Yoshizawa, 1976). Branches of
the horizontal subarticular collecting vein system, in turn, drain
into large, vertically oriented channels that course toward the
central horizontal plane of the vertebral body, where a dense
venous network is formed. The dense network is drained by
the basivertebral vein (occasionally there are two basivertebral
veins in the same vertebral body). The subarticular collecting
vein system also sends small tributaries laterally. These small
tributaries leave the vertebral body and drain into veins of the
external vertebral venous plexus (see later information).
Items of Clinical Significance. Of clinical interest are the
findings of Esses and Moro (1992), who found that long-
term intraosseous hypertension within the vessels of the
vertebral bodies is associated with an increase of pain and
severity of osteoarthritis.

20
 Chapter 2 – General Characteristics of the Spine
Clinical Anatomy of the Spine, Spinal Cord, and ANS

Superior Spinous Transverse

articular facet Pedicle process Lamina process

A B
Spinous Transverse Vertebral Pedicle Vertebral Vertebral
process process body foramen body

Spinous
process Lamina

C
Inferior
articular
facet
FIG. 2-3 Typical vertebra. A, Lateral view. B, Superior view. C, Inferior view.

21
PART ONE
Characteristics of the Spine and Spinal Cord

FIG. 2-4 Arterial supply to a typical vertebra and related tissues.

A, Superior view of a horizontal section through the level of the
vertebral body showing a lumbar segmental artery (SA) branching
from the abdominal aorta and sending many branches to feed the
dense central plexus (CP) of arteries formed within this plane of
the vertebral body. From this central plexus many small branches
ascend and descend to reach the superior and inferior margins of
the vertebral bodies (see panel B). Also, notice that the spinal ramus
of the segmental artery (SR) forms an anterior branch (AB) to the
SA vertebral body and anterior tissues of the vertebral canal, a posterior
CP branch (PB) to the posterior arch structures and posterior tissues of
the vertebral canal, and a neural branch (NB) that divides into ante-
rior (AR) and posterior (PR) radicular arteries to feed the ventral
and dorsal roots (and rootlets), respectively. B, Midsagittal section
showing the superior and inferior branches of the central arterial
AB AR
SR plexus of the vertebral body. These branches feed the arterial plex-
uses located subjacent to the cartilaginous end plates. Also notice
that the anterior branch (not labeled here) of the spinal ramus pro-
NB
vides an artery to the center of the vertebral body that helps supply
the central arterial plexus as well. The anterior branch also produces
PR an ascending (AsB) and a descending (DsB) branch, each of which
anastomoses with a corresponding artery of adjacent vertebral lev-
els. The posterior branch of the spinal ramus is shown dividing into
a large laminar artery (L) that enters the lamina and then provides
ascending (ALB) and descending (DLB) laminar branches to supply
PB
the superior and inferior articular processes, respectively, includ-
ing the subchondral bone of the articular facets. See Arterial Supply
to the Spine for further details.

DsB PB

ALB
AsB
SR

SA CP

DsB

DLB

AsB
B

22

Occasionally a vertebral body compression fracture
occurs some time (days to years) after an individual suffers
trauma to the spine. This condition is known as “delayed
posttraumatic vertebral collapse,” or Kümmell disease, and
is probably the result of damage to the nutrient arteries of
the vertebral body during the original injury. Damage to the
nutrient arteries then leads to necrosis (ischemic necrosis) of
the vertebral body and subsequent vertebral collapse (Van
Eenenaam & El-Khoury, 1993).
Osteophytes of the vertebral bodies are protrusions of the
superior or inferior aspects of the vertebral bodies that are
composed of compact bone and extend toward the adjacent
intervertebral disc and vertebral body. Anterior osteophytes
of the vertebral bodies generally are more common than
posterior ones and usually are larger. A large proportion of
vertebral columns have osteophytes by the second decade
of life, and by the fourth decade osteophytes are present in
almost 100% of vertebral columns. The size of the osteo-
phytes increases with age. There is no significant difference
between osteophyte formation on the anterior aspect of the
vertebral bodies and gender; however, males have more
anterior osteophytes than females. Osteophytes on the pos-
terior aspect of the vertebral bodies are most common in the
lower cervical and lower lumbar regions and are more com-
mon in white than in black males and females. No significant
difference exists in the prevalence of posterior osteophytes
between males and females of the same racial background
(Nathan, 1962).
Osteophytes develop slightly earlier in life in the thoracic
and lumbar regions than in the cervical and sacral regions.
However, in the fifth decade cervical osteophytes develop
more rapidly than in the other regions of the spine, and by
the seventh decade the incidence is nearly equal among cer-
vical, thoracic, and lumbar osteophytes; osteophytes of the
sacral region (only found on the first sacral segment) are the
least common (Nathan, 1962).
Anterior osteophytes can result in complete interbody
fusion. Such fusion is most common in the mid- to lower-
thoracic region and in the lower-cervical region; however,
fusion is extremely rare between C7 and T1 and between L5
and the first sacral segment (Nathan, 1962).
Osteophytes are much less common in the region of a
vertebral body in contact with the aorta, and they usually
develop in the region of the vertebral body that receives the
greatest compressive loads during normal stance or com-
mon movements. For example, osteophytes tend to develop
on the concave side of the normal curves of the spine. Ante-
rior osteophytes, which generally are the most numerous,
are most common in the thoracic region, and posterior
osteophytes are most common in the cervical and lumbar
regions of the spine (Nathan, 1962).
Bony End Plates. The ring apophyses, also known as the
ring epiphyses, are secondary centers of ossification that
develop along the periphery of the superior and inferior
aspects of the vertebral bodies before puberty (see Chapter
Chapter 2 – General Characteristics of the Spine
Clinical Anatomy of the Spine, Spinal Cord, and ANS
12). These regions fuse with the remainder of the vertebral
bodies usually by the age of 25 years. Some authors refer
to the superior- and inferior-most regions of the vertebral
body, including the area associated with the superior and
inferior ring apophyses (both before and after their fusion
with the remainder of the vertebral body), as the vertebral
end plates. However, this terminology is confusing because
the vertebral end plates (also known as the cartilaginous
end plates) refer to the parts of each intervertebral disc that
are found superior and inferior to the nucleus pulposus
and anulus fibrosus. Therefore the term “bony end plate” is
used in this text to describe the superior- and inferior-most
regions of the vertebral bodies. During the time of puberty
these regions are also associated with the ring apophyses,
and the term bony end plate applies to the region of the
ring apophyses as well, both before and after their fusion
with the remainder of the vertebral bodies. The term verte-
bral end plate, or cartilaginous end plate, is used in this text
to refer to the superior and inferior aspects of each inter-
vertebral disc.
The central region of each bony end plate has a mottled
appearance from birth to 6 months of age. This appearance
results from vascular markings (holes) formed by small
blood vessels that at this early age extend to the cartilaginous
end plate from deep within the vertebral body.
Between 6 months and 2.5 years of age the mottled
appearance of the central bony end plate diminishes (as the
blood vessels disappear), and the end plate retains this some-
what smoother appearance for the remainder of the life of
the vertebra. However, between 6 months and 25 years of
age the peripheral margins of the end plates become promi-
nently scalloped, showing prominent ridges and sulci. This
scalloping results in a denticulate, or toothlike, appearance
along the vertebral margins, having an appearance similar
to that of the outer margins of the epiphyseal plates of other
bones of the body. The scalloping of the bony end plate is
variable from one vertebra to the next and is most promi-
nent in the lower thoracic and upper lumbar regions, and
less pronounced in the cervical and thoracic regions. The
scalloping is thought to increase stability during the appli-
cation of shear forces to the spine (forces that tend to slide
one vertebra over the vertebra immediately inferior to it).
Resistance to shear forces also explains why the scalloping is
less prominent in the majority of the thoracic region and the
entire cervical region, where the ribs and uncinate processes
(see Chapter 5), respectively, resist shear forces in these
areas. The ridges and sulci of the bony end plates become
more prominent until approximately 12 to 25 years of age
when the bone from the anular apophysis is laid down, cre-
ating an enlarging smooth ridge of bone that follows the
peripheral margins of the superior and inferior surfaces of
the vertebral bodies (Edelson & Nathan, 1988). The cortical
bone of the central region of the superior and inferior bony
end plates (i.e., the region of each end plate adjacent to the
nucleus pulposus) is thinnest, and the end plates increase in
thickness from this central region to the periphery (Grosland
23
PART ONE
Characteristics of the Spine and Spinal Cord
& Goel, 2007). Consequently, the periphery of the bony end
plates can withstand more loads before failure than the more
central regions of the end plates (Bailey et al., 2011).
Items of Clinical Significance. Beginning in the latter
aspect of the third decade, osteophytes develop on the verte-
bral bodies, usually just adjacent to the bony end plate. That
is, an osteophyte usually spares the bony end plate (there is
usually a distinct sulcus between each osteophyte and the
related bony end plate). The osteophytes then arch across
the bony end plate, extending toward the adjacent vertebra
(Edelson & Nathan, 1988).
Osteoporotic changes also can occur in the bony end
plate. These changes usually begin toward the end of the fifth
decade and progress until death. Osteoporotic changes in the
bony end plates assume the appearance of lytic, or “punched
out,” areas of the bone (Edelson & Nathan, 1988).
Vertebral Arch
The vertebral (posterior) arch has several unique structures
(see Fig. 2-3). These include the pedicles, laminae, and supe-
rior articular, inferior articular, transverse, and spinous
processes. Each of these subdivisions of the vertebral arch is
discussed separately in the following sections.
Pedicles. The pedicles (see Fig. 2-3) create the narrow ante-
rior portions of the vertebral arch. They are short, thick, and
rounded and attach to the posterior and lateral aspects of
the vertebral body. They also are placed superior to the mid-
point of a vertebral body. Because the pedicles are smaller
than the vertebral bodies, a groove, or vertebral notch, is
formed above and below the pedicles. These are known as
the superior and inferior vertebral notches, respectively. The
superior vertebral notch is more shallow and smaller than
the inferior vertebral notch.
The percentage of compact bone surrounding the inner
cancellous bone of the pedicles varies from one region of
the spine to another and seems to depend on the amount
of motion that occurs at the given region (Pal et al., 1988).
More compact, stronger bone is found in regions with
more motion. Therefore the pedicles of the middle cer-
vical and upper lumbar regions contain more compact
bone than the relatively immobile thoracic region. The
thoracic pedicles are made primarily of cancellous bone
(Pal et al., 1988).
There are significant differences in the relative size of var-
ious parts of vertebrae among various ethnic populations,
with those from Western populations generally having larger
structures than those from Asia. This is true for the pedicles
(Chadha et al., 2003).
Laminae. The laminae (singular, lamina) are continuous
with the pedicles. They are flattened from anterior to pos-
terior and form the broad posterior portion of the vertebral
arch (see Fig. 2-3). They curve posteromedially to unite with
the spinous process, completing the vertebral foramen. Xu
and colleagues (1999) performed a detailed morphometric
24
study of the laminae of the entire vertebral column. They
concluded that, generally speaking, the laminae of males are
slightly larger than those of females. The laminae generally
increase in height from C4, which are the shortest (10.4 +
1.1 mm), to T11, which are the tallest (25.1 + 2.5 mm). The
height of the laminae then begin to decrease slowly from T12
to L4, and then more markedly at L5. However, the lami-
nae are widest at L5 (15.7 + 2.0 mm) and narrowest at T4
(5.8 + 0.8 mm). The cervical laminae are wide (rivaling those
of L5), the thoracic laminae (with the exception of T11 and
T12) are narrow, and the width steadily increases from T11
to L5. The laminae are thickest at T2 (5.0 + 0.2 mm) and least
thick at C5 (1.9 + 0.6 mm), with the thickness of the laminae
decreasing from the upper to the lower thoracic regions. The
lower cervical laminae are the least thick of the vertebral col-
umn, and the lumbar laminae are of intermediate thickness
(Xu et al., 1999).
Spinous Process. The spinous process (spine) of each ver-
tebra (see Fig. 2-3) projects posteriorly and often inferiorly
from the laminae. The size, shape, and direction of this pro-
cess vary greatly from one region of the vertebral column to
the next (see individual regions). A spinous process also may
normally deviate to the left or right of the midline, and this
can be a source of confusion in clinical practice. Therefore
a deviated spinous process seen on x-ray film or palpated
during a physical examination frequently is not associated
with a fracture of the spinous process or a malposition of the
entire vertebra.
The spinous processes throughout the spine function as a
series of levers both for muscles of posture and for muscles
of active movement (Standring et al., 2008). Most of the
muscles that attach to the spinous processes act to extend
the vertebral column. Some muscles attaching to the spinous
processes also rotate the vertebrae to which they attach.
Lateral to the spinous processes are the vertebral grooves.
These grooves are formed by laminae in the cervical and
lumbar regions. They are much broader in the thoracic
region and are formed by both the laminae and transverse
processes. The left and right vertebral grooves serve as gut-
ters. These gutters are filled with the deep back muscles that
course the entire length of the spine.
The spinous process of a specific vertebra frequently
can be identified by its relationship to other palpable land-
marks of the back. Chapter 1 provides a detailed account of
the relationship between the spinous processes and other
anatomic structures.
Vertebral Foramen and the Vertebral Canal. The vertebral
foramen is the opening within each vertebra that is bounded
by the structures discussed thus far. Therefore the vertebral
body, the left and right pedicles, the left and right laminae,
and the spinous process form the borders of the vertebral
foramen in a typical vertebra (see Fig. 2-3). The size and
shape of the vertebral foramina vary from one region of the
spine to the next and even from one vertebra to the next.

The vertebral canal is the composite of all of the vertebral
foramina. This region houses the spinal cord, nerve roots,
meninges, and many vessels. The vertebral canal is discussed
in more detail later in this chapter.
Transverse Processes. The transverse processes project lat-
erally from the junction of the pedicle and lamina (pediculo-
laminar junction) (see Fig. 2-3). Like the spinous processes,
their exact direction varies considerably from one region
of the spine to the next. The transverse processes of typi-
cal cervical vertebrae project obliquely anteriorly between
the sagittal and coronal planes and are located anterior to
the articular processes and lateral to the pedicles. The left
and right cervical transverse processes are separated from
those of the vertebrae above and below by successive inter-
vertebral foramina. The thoracic transverse processes are
different and project obliquely posteriorly and are located
behind the articular processes, pedicles, and intervertebral
foramina (see Fig. 6-1). They also articulate with the ribs.
The lumbar transverse processes (see Fig. 7-2) lie in front of
the lumbar articular processes and posterior to the pedicles
and intervertebral foramina.
The transverse processes serve as muscle attachment sites
and are used as lever arms by spinal muscles. The muscles
that attach to the transverse processes maintain posture and
induce rotation and lateral flexion of single vertebrae and the
spine as a whole.
Each transverse process is composed of the “true”
transverse process (diapophysis) and a costal element.
Each costal element (pleurapophysis) develops as part of
the neural arch (see Fig. 12-13). The costal elements of the
thoracic region develop into ribs. Elsewhere the costal ele-
ments are incorporated with the diapophysis and help to
form the transverse process of the fully developed verte-
bra. The cervical costal elements are composed primarily
of the anterior tubercle but also include the intertubercu-
lar lamella and a part of the posterior tubercle. The lumbar
costal elements are the anterior aspects of the transverse
processes, and the left and right sacral alae represent the
costal processes of the sacrum. The cervical and lumbar
costal processes occasionally may develop into ribs. This
occurs most frequently in the lower cervical and upper
lumbar regions. These extra ribs may be a cause of dis-
comfort in some individuals. This is particularly true of
cervical ribs (see Chapter 5).
Superior Articular Processes. Like the transverse pro-
cesses, the superior articular processes (zygapophyses) and
facets also arise from the pediculolaminar junction (see Fig.
2-3). The left and right superior articular processes project
superiorly, and the articular surface (facet) of each articular
process faces posteriorly, although the precise direction var-
ies from posteromedial in the cervical and lumbar regions
to posterolateral in the thoracic region. (The superior and
inferior articular facets are discussed in more detail later in
this chapter under Zygapophysial Joints.)
Chapter 2 – General Characteristics of the Spine
Clinical Anatomy of the Spine, Spinal Cord, and ANS
Inferior Articular Processes. The left and right inferior
articular processes (zygapophyses) and facets project
inferiorly from the pediculolaminar junction, and the
articular surface (facet) faces anteriorly (see Fig. 2-3).
Again, the precise direction in which they face varies from
anterolateral (cervical region) to anteromedial (thoracic
and lumbar regions).
Adjoining zygapophyses form zygapophysial joints
(Z joints), which are small and allow for limited movement.
Mobility at the Z joints varies considerably between vertebral
levels. The Z joints also help to form the posterior border of
the intervertebral foramina. The anatomy of the Z joint is
discussed after the next section.
Functional Components of a Typical Vertebra
Each region of a typical vertebra is related to one or more
of the functions of the vertebral column mentioned at the
beginning of this chapter (support, protection of the spinal
cord and spinal nerve roots, and movement) (Fig. 2-5). In
general, the vertebral bodies help with support, whereas the
pedicles and laminae protect the spinal cord. The superior
and inferior articular processes help determine spinal move-
ment by the facing of their facets. The transverse and spinous
processes aid movement by acting as lever arms on which the
muscles of the spine act.
The posterior arches also function to support and trans-
fer weight (Pal et al., 1988), and the articular processes of
the cervical region form two distinct pillars (left and right)
that bear weight. In addition, the laminae of C2, C7, and the
upper thoracic region (T1 and T2) help to support weight.
Therefore a laminectomy at these levels results in marked
cervical instability (Pal et al., 1988), whereas a laminectomy
from C3 to C6 is relatively safe.
The pedicles also act to transfer weight from the poste-
rior arch to the vertebral body, and vice versa in the cervical
region (Pal et al., 1988), but only from the posterior arch to
the vertebral bodies in the thoracic region. The role of the
pedicles in the transfer of loads is yet to be completely deter-
mined in the upper lumbar region, but the trabecular pattern
of the L4 and L5 pedicles seems to indicate that the majority
of load may be transferred from the vertebral bodies to the
region of the posterior arch in these two vertebrae. This is
discussed in further detail in Chapter 7, which is devoted to
the lumbar spine.
Zygapophysial Joints
The articulating surface of each superior and inferior articular
process (zygapophysis) is covered with a 1- to 2-mm-thick layer
of hyaline cartilage. This hyaline-lined portion of a superior
and inferior articular process is known as the articular facet.
The junction found between the superior and inferior articular
facets on one side of two adjacent vertebrae is known as a zyg-
apophysial joint. Therefore, a left Z joint and a right Z joint are
between each pair of vertebrae. Figure 2-6, A, shows the Z joints
of the cervical, thoracic, and lumbar regions. These joints also
are called facet joints or interlaminar joints (Giles, 1992). The
25
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN